Dysmenorrhea

Most menstruating woman experience some discomfort for a few days during each cycle.  However, in some cases the pain is severe or long-lasting enough to interfere with a woman’s daily activities.  This condition is known as dysmenorrhea.

Your Menstrual Cycle

The menstrual cycle occurs as the body prepares for pregnancy each month. A cycle is counted from the first day of one period to the first day of the next period. The average menstrual cycle is 28 days long, but cycles can range anywhere from 21 to 35 days in adults.  Levels of the hormones estrogen and progesterone rise and fall during the month to make the menstrual cycle happen.

In the first half of the cycle, levels of estrogen begin to rise and make the lining of the uterus grow and thicken. At the same time, an egg in one of the ovaries starts to mature. At approximately halfway through the cycle, the egg leaves the ovary. This is called ovulation. After the egg has left the ovary it travels through the fallopian tube to the uterus. Hormone levels rise and help prepare the uterine lining for pregnancy.  A woman is most likely to get pregnant during the three days before ovulation or on the day of ovulation.

If the egg is fertilized by a man’s sperm cell and attaches to the uterine wall, the woman becomes pregnant. If the egg is not fertilized, it will break apart. If pregnancy does not occur, hormone levels drop, and the thickened lining of the uterus is shed.  This shedding is the monthly period.

Menstrual Pain

When the old uterine lining begins to break down and shed, substances called prostaglandins are released. These substances cause the muscles of the uterus to contract. When the uterine muscles contract, they constrict the blood supply to the endometrium. This contraction blocks the delivery of oxygen to the tissue of the endometrium which, in turn, breaks down and dies.

After the death of this tissue, the uterine contractions literally squeeze the old endometrial tissue through the cervix and out of the body by way of the vagina. These contractions sometimes cause pain, usually during a menstrual cycle where an egg is released. 

Symptoms of Primary Dysmenorrhea

Either just before or at the beginning of the menstrual cycle, a woman with dysmenorrhea will experience cramping in the lower abdomen. The pain may be continuous, or may come and go, and may extend to the lower back and legs. In addition, the woman may experience any or all of the following:  headache, nausea, diarrhea or constipation, and the need to urinate frequently. In the most severe cases, vomiting also occurs.  Symptoms are usually at their worst 24 hours after beginning, and usually last only 48 hours or so.  Women with dysmenorrhea are also more likely to pass blood clots from the lining of the uterus, which causes more pain.  Pelvic pain that is the result of menstruation is known as primary dysmenorrhea. 

Secondary Dysmenorrhea

Secondary dysmenorrhea is caused by a problem with the uterus, fallopian tubes, or ovaries rather than the normal production of prostaglandins.  It may feel exactly like primary dysmenorrhea, or the pain may begin earlier, last longer, or not go away when the period ends.  A woman with secondary dysmenorrhea may also experience pain at other times of the month or during sexual intercourse. The most common causes of secondary dysmenorrhea are:

Endometriosis

• Endometriosis is the growth of cells similar to those that form the inside of the uterus (endometrial cells), but in a location outside of the uterus. Endometrial cells are the same cells that are shed each month during menstruation. The cells of endometriosis attach themselves to tissue outside the uterus and are called endometriosis implants.
• These implants respond to the hormones of the menstrual cycle in the same way as the normal endometrium. The implants build up during the month, then break down and during menstruation they bleed internally.
• Blood from the implants has no way to exit the body.  Internal bleeding, tissue inflammation and scarring result, causing the symptoms of endometriosis.
   

Uterine Fibroid Tumors

• Fibroid tumors are usually non-cancerous tumors found most often in the uterus of women in their 30's and 40's.  They occasionally develop on other organs which contain smooth muscle cells.
• Fibroid tumors are solid tumors which are made of fibrous tissue, hence the name 'fibroid' tumor. Most often fibroids occur as multiple tumor masses which are slow-growing and often cause no symptoms.

Pelvic Inflammatory Disease

• Pelvic inflammatory disease (PID) is caused by an infection that starts in the vagina. Most often, it is caused by a sexually transmitted disease (STD). The infection spreads upward into the uterus, fallopian tubes, and pelvis.
• Women who use intrauterine devices (IUDs) are at increased risk for PID for the first three months after insertion. Rarely, the bacteria that cause PID enter the body during childbirth or abortion.

An Intrauterine Device

• An IUD is a contraceptive device that is positioned inside the uterus to prevent pregnancy. They work by changing the lining of the uterus and fallopian tubes, thereby  affecting the movements of eggs and sperm so that fertilization does not occur.

Treatment

Treatment of dysmenorrhea depends on the cause of the problem. In most cases, symptoms are relieved by nonprescription anti-inflammatory drugs (NSAIDS).  These drugs include ibuprofen and naproxen.  If a woman has a history of dysmenorrhea, the healthcare provider may recommend taking these medications up to two days before the menstrual period begins, and continuing them for one to two days after it starts.

Women with severe primary dysmenorrhea may be prescribed a low-dose birth control pill. Because birth control pills prevent an egg from being released each month, the menstrual period is generally lighter and lasts for a shorter time.

Secondary dysmenorrhea is relieved by treating the cause.  Inflammation of the fallopian tubes can often be treated with antibiotics.  Fibroid tumors can be surgically removed, or sometimes shrunk with hormone therapy.  If the fibroids are extremely large or cause severe pain, the entire uterus may need to be surgically removed. This procedure is called a hysterectomy, and is also used to treat severe endometriosis. This is not an option for a woman who may want to become pregnant, since a woman who has had a hysterectomy can no longer conceive a child.

Remember

It is normal to have some pain during your menstrual cycle, but if it interferes with your daily routine, see your physician or midwife.   She or he can determine if the pain is caused by a condition that needs to be treated and can help to find the best treatment to relieve your symptoms.